Emergency Infant Feeding Surveys
Assessing infant feeding as a component of
emergency nutrition surveys: Feasibility studies
from Algeria, Bangladesh and Ethiopia
Marko Kerac1, Marie McGrath3, Fathia Abdalla2, Andrew Seal1
1 UCL Centre for International Health and Development London;
2 UNHCR Geneva; 3 ENN, Oxford
Supported by ENN &
Funded by UNICEF-led IASC Nutrition Cluster
1
Aim
Investigate feasibility & utility of including
standard indicators of
infant feeding practice
in routine nutrition surveys.
2
Objectives
1)
Describe the sample size assumptions and
calculations required
Assess the precision achieved when
measuring the indicators in 4 emergency
nutrition surveys
2)
3
Background
Why good quality data is important:
-
Correct response to vulnerable situation
-
-
Assessing programme impact
-
-
-
Start programme when indicated (‘threshold’)
No programme when there is no need for one (efficient
use of resources)
Correct baselines
True impact vs artefact (poor validity; poor precision)
Assessing trends
-
True differences vs artefact
4
Methods
Study design
~ Descriptive
~ Summary of key methodological features & results of:
4 recent emergency nutrition surveys.
~Selected purposively
data on infant feeding (0 to 5.9m & 6 to 24 months)
A.Seal, CIHD/ICH ~ lead investigator on all surveys
5
Methods
Settings

Refugee populations in



Algeria
Bangladesh
Resident populations in


Ethiopia (highland)
Ethiopia (lowland)
Sampling (within each survey)

‘Traditional’ 2 stage, 30x30 cluster design.
6
Methods
Participants

Children aged 6 to 59.9 months
=
main population of interest in most nutrition
surveys, including the four described.

Young infants aged 0 to 5.9 months
=
additional to the above
7
Methods
Measurements


3-4 day team training ( = standard)
Included anthropometry, morbidity questions and 24
hour recall food frequency questionnaire




ESTABLISHED / CONSISTENT / VALIDATED
(Mary Lung’aho et al – previous presentation)
current feeding practices (all infants, ages 0 to 23.9m)
Focus groups / key informants for inclusion of specific local
food items
Questionnaires were translated into local languages and
piloted prior to the start of each survey.
8
Methods
Sample size (1)


Emergency nutrition cluster surveys, where
prevalence data limited,  900 children aged 6-59 m
To calculate the number of infants required:
1) likely prevalence,
2) required precision,
3) anticipated ‘design effect’ (=loss of power in a cluster
sampling method vs simple random sample)
~ routine to assume 2 for standard anthro indicators
(cases localized, not random)  x2 sample size
~ we assumed infant feeding practices not localised
 design effect=1  no sample size increase
9
Methods
Sample size (2)

To determine prevalence of EBF (0-5.9m):



30% prevalence assumed
 based on global statistics, [ref: UNICEF Statistics
http://www.childinfo.org/eddb/brfeed/index.htm]
Design effect = 1
desired precision of +/- 15 %,
 adequate for a baseline needs assessment
*** sample size = 36 infants ***
10
Methods
Sample size (3)

To determine prevalence of continued BF at 12 and
24 months:


60 % prevalence assumed,
 also based on available global estimates, and a
precision of +/- 20 %.
sample size:
*** 24 children aged 12 to 15.9 months ***
*** 24 children age 20 to 22.9 months ***
Population pyramid  ? recruit from the 900 ‘core’ survey
11
Methods
Statistical methods ~ for individual surveys

Data entry, validation, cleaning  EpiInfo v.6.04d

Separate files for:
0-5.9 month
&
6-59.9 months

Analysis  EpiInfo v.6.04d and SPSSv11
12
Methods
Statistical methods ~ key to this paper….

For each indicator…
in each survey…
we retrospectively calculated:



Design effect
Standard error
Actual precision achieved
13
Results
Survey site
Date of survey
Total Population
Survey sample***
Infants (0-5 m)
Children (6-59 m)
Sample ratio
0-5 m:6-59 m
Survey measures
Infants (0-5 m)
Children (6-23 m)
Children (24-59 m)
Algeria
Saharawi
Refugee
Camps,
Tindouf
12th - 22nd
Sept. 2002
154,670
Bangladesh
Myanmar
Refugees
Camps,
Cox’s Bazar
18th - 24th Aug.
2003
19,804
Ethiopia
Aroressa
Woreda,
Sidama Zone *
Ethiopia
Aroressa
Woreda,
Sidama Zone **
12th - 25th Mar.
2004
84,655
12th - 25th Mar.
2004
40,675
92
907
98
923
52
918
46
921
1:10
1:9
1:18
1:20
FFQ, WH, HA
FFQ, WH, HA
WH, HA
FFQ
FFQ, WH, HA
WH, HA
FFQ
FFQ, WH, HA
WH, HA
FFQ
FFQ, WH, HA
WH, HA
14
Results (t.b.c…)
Indicator*
Ever breastfed
Timely initiation of
breastfeeding
Exclusive breastfeeding
Age group
analysed
Algeria
0-23 m
n=371
93.3%
(95.3, 99.4)
DE=tbc
SE=tbc
RP=tbc
0-23 m
n=369
12.7%
(8.8-16.7)
<6 m
Continued BF at 12 m
12-15 m
n=87
2.3%
(0.0-6.8)
n=82
84.1%
(75.3-93.0)
Bangladesh
Ethiopia
(highland areas)
Ethiopia
(lowland areas)
n=360
97.8%
n=261
95.0%
(92.1-97.9)
n=238
99.6
(98.8-100.0)
n=357
42.3%
n=260
93.1%
(88.5-97.6)
n=235
91.1%
(85.1-97.1)
n=52
71.5%
(58.2-84.1)
n=64
95.3%
(90.7-99.9)
n=46
47.8%
(32.6-63.0)
n=57
96.5%
(92.0-100.0)
n=92
53.3%
n=67
95.5%
etc… for 10 indicators15
Discussion
Key result and interpretation

Successful inclusion of infant feeding indicators
into a standard nutrition survey is feasible and
achievable.
 Diverse physical and social settings:
refugee camps ~~> resident populations
Sahara desert ~~> Ethiopian highlands.
16
Discussion
Mortality & morbidity consequences

n=4 surveys too small to reliably interpret the
mortality and morbidity implications
BUT notable that
All 4 sites far short of ideal infant feeding practice

e.g.


EBF as low as 2% in Algeria
Best EBF, in the Ethiopian highlands only 71.5%
 potential for harm (6-59.9m MAM/SAM high)
 need for interventions
17
Discussion
Including IF indicators important because:


Better planning
Identify & address potential negative effects of emergency
interventions



e.g. effects of code violations
Increased awareness of infant feeding issues in communities
surveyed
( In principle ), problems can be addressed proximally, before
MAM/SAM evolves
18
Discussion
Other issues
(work in progress)

Anthropometry in 0 – 5.9m
Difficult in this age! (e.g scales)
 Only 1 of 4 surveys measured
young infant anthropometry
 Interpretation
 NCHS vs WHO standards

Binns C, Lee M. Will the new WHO growth
references do more harm than good? Lancet
2006; 368: 1868–69 (figure)
19
Discussion
Other issues (future work)

Survey methodology
LQAS vs 30x30
20
Conclusions





Our preliminary results suggest that inclusion of
already available, validated questions about infant
feeding practice is feasible and achievable
These may be integrated within current emergency
nutrition survey designs
We suggest that there are strong arguments for
routine inclusion
However, we acknowledge that all data collection
and analysis has a cost
Any data collection should only take place in an
emergency context when it will be used to inform
decision making.
21
Thank You
22
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